Episodes of Care

An episode is the collection of care provided to treat a particular condition for a given length of time. During the first phase of the payment initiative, Medicaid and the private insurers initially introduced five episodes of care: upper respiratory infections (URI), total hip and knee replacements, congestive heart failure (CHF), attention deficit/hyperactivity disorder (ADHD), and perinatal.  Providers share in the savings or excess costs of an episode depending on their performance for each episode. For some episodes, providers will submit a small amount of information not currently available through the billing system through the Provider Portal. For each episode, all treating providers will continue to file claims as they have previously and will be reimbursed according to each payer’s established fee schedule. The payer will identify the Principal Accountable Providers (PAP) for each episode through claims data.